Nepal has one of the highest maternal mortality rates in the world, with the government estimating that 4,500 women die each year from pregnancy-related deaths. According to the Ministry of Health, the maternal mortality rate is 530 per 100,000 births, but experts believe the figure is much higher. The American research organisation, Population Reference Bureau, puts the figures as 830 per 100,000 births.
In the absence of enough trained birth attendants, low resources, inadequate health facilities and illiteracy are just some of the crucial issues contributing to poor maternal healthcare in Nepal. For health organisations and UN agencies like the United Nations Population Fund (UNFPA), the challenge for healthcare delivery has become even more difficult given the escalation of the nine-year-old armed conflict between the Maoists and the government.
Sultan Aziz, Director of Asia-Pacific Division of UNFPA spoke to IRIN about the state of reproductive health during a brief visit from his New York office to Nepal:
QUESTION: The state of reproductive health in Nepal still looks bleak. Where were we failing?
ANSWER: It’s not a question of failure but priorities. The issue of dealing with women’s reproductive health is an ongoing challenge even in some middle income and developing countries. There is no argument that the status of women is not where it should be. Given the complex development challenges Nepal faces, it would be appropriate to say that these are ongoing challenges. Clearly, the issues relating to governance of the health system is important. Given the complex development challenges Nepal faces, it would be appropriate to say that these are ongoing challenges especially in the present conflict situation.
Q: Maternal mortality is still poor in Nepal. Do we lack really effective programmes to deal with this issue?
A: It is not the lack of programmes as there are many which have been around for a long time. It is absolutely crucial that the government puts in more resources and makes it more of a priority. I think the international community is quite committed. You will find there is really serious commitment to health services from us, but recent events have made it difficult to go to those places where indicators are not coming down.
Q: Some health experts say that the ongoing Maoist conflict has had the least impact on health work. Do you agree with that?
A: No, I completely disagree with that. I think there’s a perception that somebody in a dire health situation will get help. But the argument should be that the very structure that supports the health system is suffering. If a particular road is blocked and a woman cannot reach the hospital to deliver, she dies or faces some complication. Some combatants might be sympathetic or might say yes we want you to come and deliver drugs. In my view, if health is to become completely neutral, then the efforts and commitment on both sides — both the antagonist and protagonist — have to be very clear that they are committed to saving lives, not to destroying them. That’s a position I feel strongly about.
Q: Is the conflict making the situation worse for the women and children?
A: The people who usually suffer the most in conflict are women and children. Men have a variety of opportunities and possibilities to leave the conflict area. But women and children cannot travel like men. But when they do travel, they end up in a camp. They have to maintain the children and bear heavy burdens. They are always in vulnerable situations. They become easy prey for rape and many other levels of exploitation. We take the issue very seriously. We have to redouble our efforts to ensure that women should be protected at all costs.
Q: Has conflict affected UNFPA’s work as well?
A: I think it’s a fact that the conflict has affected everyone. It’s not normal and is disruptive. The fact is that the professionals who we have invested in for years in Nepal cannot access those areas to provide services irrespective of who the population is. It’s not a good situation. Now we have to train our co-workers and people who work with us to understand what are the realities in a crisis, to be able to respond appropriately. The question is how do we respond? What strategy do we and health workers adopt? Then it’s only a question of protection and mitigating whatever risk there is.
The key issue is about saving lives, protecting people and ensuring vulnerabilities decrease. We should no longer pretend that we can continue to do development in a crisis and in absence of security. That should be very clear. The challenges are still developmental but the equation has turned upside down. The consequences are not just about physical security but also about emotional and financial security and livelihood. Every facet of life is disrupted. Despite intentions of parties to the contrary, the realities are different. The reality is predatory and about vulnerability. Those are the things that we have to be able to address in our existing work.
Q: A lot of poor women die in villages due to a lack of trained birth attendants. So much has been planned in the capital but little done on the ground.
A: I think people in responsible places have to make choices. Our duty as UN officials is to make sure that we persuade our colleagues whoever and wherever they are to do the right thing by taking the difficult decision to help as long as the nature of our work is indeed humanitarian in character. We should continue our support until life can return back to normal. It is clear that our first and foremost task is to save as many lives as possible. And yet the instruments may not be different from what they’ve always been.
Q: Nepal’s population growth is rapid. What are the development consequences if such a trend continues?
A: In a sense, I’m not so scared by population growth. There are varieties of indicators that you can look at. You have to look at quality of life indicators, quality of education, and reduction of poverty. If you look at those composite indicators, then you can say that we can afford to have a certain growth in population. In the absence of all those indicators, the population growth of 4.5 Total Fertility Rate (TFR) is a cause for concern because it squeezes your doubling period and yet you are faced with the challenge of slow economic growth and deteriorating infrastructure. You have to make choices where you are going to put money. If you put your money in infrastructure, then you are going to miss something important.
The idea here is that much has to be done on family planning, which is crucial. It’s not just about passing out contraceptives to people. The process is much more complex. It’s a composite approach again to being able to provide integrated services. In Nepal there is an attempt to do that and it has been done in a number of places and is showing promising results but it needs to be expanded much more. The government needs to take this approach really in a broad sense in order to cut the fertility rate.
Q: Nepal started family planning programmes at the same time as other countries like Indonesia but has lagged far behind. What can we learn from others?
A: Certain types of integrated services like change in reproductive health, quality care, family planning, and providing services to youth are needed. Girls get married early in Nepal and so delaying the age of marriage is important and these can all come through a behavioural change in communication strategy. More needs to be done, more money needs to be put into it and more infrastructure needs to be built. Those are experiences that some countries have engaged in. There’s nothing magical about it. It not only takes time but also requires consistent and sustained commitment to that type of work. These are things that only government can make happen.
Q: What impact has UNFPA’s work made in Nepal?
A: UNFPA has had a reasonable impact. We have gone through a variety of stages in Nepal in terms of assistance, and obviously in capacity building. We have contributed to His Majesty’s government over the years and that has paid dividends. We have done a considerable amount of work in reproductive health as well as in terms of trying to deal with the issues related to youth. But UNFPA is a small donor. Our contribution to Nepal, however, is not just the resources or money. It's also about advocacy and working closely with the government - constantly trying to remind and sometimes push it a little bit. Through our training, we have created a lot of sensitisation on why the government needs to adopt certain policies. So in that sense, the overall impact has been positive. But now the challenge is even greater and there is a need for more focus and the intensity with which the government has to address needs. There is a lot less room for maneuvering in terms of putting things off because that could have a grave consequence for Nepal.
This article was produced by IRIN News while it was part of the United Nations Office for the Coordination of Humanitarian Affairs. Please send queries on copyright or liability to the UN. For more information: https://shop.un.org/rights-permissions
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